Vitiligo

1. VITILIGO SURGERY

2. INTRODUCTION
Basic objective : to produce cosmetically acceptable repigmentation of the
vitiliginous lesions.
Basic principle : to introduce melanocytes into the lesional skin, which will then
establish and function as epidermal melanin units.

3. METHODS OF SURGERY

4. PATIENT SELECTION
Stability of vitiligo is considered as the most important parameter while opting for any
transplantation technique to treat vitiligo.
 CONCEPT OF STABILITY IN VITILIGO
Stability indicates absence of new lesions and absence of spread of existing lesions.
There are several aspects which need consideration while considering surgery:
What should be the minimum duration of stability?
 Is stability patient specific or area specific or lesion specific?
Validity of test grafting (TG).
 Importance of Koebner’s phenomenon.
 How long does stability last?

6. Test grafting (TG) consists of placing
six to eight punch grafts within a
vitiligo lesion and observing over the
next 12 weeks.
Unequivocal repigmentation
occurring beyond 1 mm from the
border of the test graft indicates a
positive test and therefore is an
indicator of stability .

7. CASE SELECTION
Surgery is indicated for patients with
 stable lesions of vitiligo vulgaris,
 localized or segmental vitiligo lesions,
 though it may be done for all types of vitiligo (including segmental, generalized and acrofacial
types), that do not respond to medical treatment and are stable.
 A test graft may be considered whenever there is a doubt about the stability, or there is doubtful
history.
 Acral lesions do not respond well to surgery and hence such patients should be counseled properly.
 Age of the patient is an important consideration, though there is no age limit for surgery. Younger
patients respond better to surgery but performing surgery in children may need general anesthesia,
with its inherent risks and in whom the future course of the disease is extremely variable.

8. PATIENT EXAMINATION
History taking should include questions about occurrence of recent lesions, increase in size of
the existing lesions, occurrence of lesions at site of injury and family history.
Physical examination should include proper systemic and cutaneous examination to rule out
any underlying conditions, presence of keloids, etc.
A detailed consent form describing the procedure and possible complications should be signed
by the patient.
The consent form should specifically state the limitations of the procedure, possibility of future
disease progression and the need for repeated procedures for satisfactory results.
Preoperative photography is of vital importance, as in any surgical method of treatment and it
also helps in medicolegal situations.

9. PREOP INVESTIGATIONS
Routine investigations such as
hemoglobin estimation,
blood counts, bleeding and clotting time, and
blood sugar estimation are adequate in most cases.
 In elderly patients, ECG may be needed.

10. CHOICE OF METHOD OF SURGERY

12. AUTOLOGOUS MINI
PUNCH GRAFTING

13. PROCEDURE
After proper assessment of the stability status, routine
physical examination and investigations, an informed
consent is taken from the patient.
The donor and recipient areas are surgically prepared.
1. The instruments required are 1.5 or 1.2 mm punches,
small jeweler’s or graft holding forceps and small curved tip
scissors
2. Recipient area is prepared first. 2% lignocaine with or
without adrenaline is infiltrated as local anesthetic.

14. 3. To minimize the chance of
developing any perigraft halo, the
initial recipient chambers are made
on or very close to the border of the
lesion. The punched out chambers
are spaced according to the result of
TG or at a gap of 5–10 mm from
each other.

15. 4. The donor area is either upper lateral portion of thigh or gluteal area. Punch
impressions are made very close to each other so that from a small area maximum
number of grafts can be taken.
5. Same sized punches are used for both donor and recipient area.
6. The grafts were placed directly from donor (buttock or upper thigh) to the recipient
areas. This speeds up the procedure and lessens the chance of infection. Care is taken, so
that the graft edges are not folded, the tissue is not crushed or placed upside down. The
needle of the syringe or the tip of the scissors is used for proper placement of grafts in
the recipient chambers.
7. Hemostasis is achieved by pressing a saline soaked gauze piece over the area.
8. For the recipient area three layers of dressing from inside out were: paraffin-
embedded nonadherent sterile gauze (Jelonet®), sterile Surgipad® and bioocclusive
Micropore®
9. For the donor area only Surgipad® and Micropore® are used.

17. 10. The recipient area may be immobilized if necessary. Proper instructions for
special areas like lips are necessary. To secure the recipient area these patients
are advised to take liquid diet for first 24 hours, preferably with a straw. Patients
are allowed normal diet after this period.
11. Sometimes dressings are opened after 24 hours to look for any
dislodgement of grafts, if found any, they are replaced.
12. Finally, after 4–7 days the dressings are removed.

19. FOLLOW UP AND COURSE OF EVENTS
Postsurgically the patients are exposed to PUVA or PUVASOL (psoralen plus ultraviolet A from
solar radiation) or NB-UVB22 or even kept as such in some studies.
Follow up - fortnightly for initial 2 months and then monthly up to complete repigmentation is
achieved.
In the donor site, after healing with secondary intention, minimal superficial scarring is
expected and acceptable. Scabs may fall off from the recipient site within 7–14 days.
Perigraft repigmentation is expected to start around 3–4 weeks.
The entire depigmented and grafted area is expected to be completely repigmented within 3–6
months, based on the area of grafting and body part involved

20. COMPLICATIONS

22. SUCTION BLISTER ROOF
GRAFTING

23. INTRODUCTION
This is a method in which epidermis is separated from
dermis by prolonged suction at a negative pressure to
donor site followed by transplanting the roof of the
blister to the dermabraded vitiliginous recipient site.
 INDICATIONS : primarily for small lesions of localized
stable vitiligo, especially over face.
 INSTRUMENTS :
Disposable syringes 10 cc/20 cc and 50 cc, 3-way
cannulas, dermabrader manual/electrical, iris scissors,
non- toothed forceps, artery forceps and radiosurgical
unit.

24. PROCEDURE
PREPARATION : Preferred donor sites for SBG include
medial aspect of forearm,
 medial/lateral aspect of upper arm,
medial or posterior aspect of upper thigh.
The area is surgically prepared with shaving, local cleaning with iodine and spirit and infiltrated
with 1% xylocaine as a field block .

25. APPLICATION OF SUCTION
The suction apparatus for suction may include
suction through glass funnels or syringe suction.
Syringe suction is applied as follows:
 The plunger of the 20 cc syringe is removed and
one end of the 3-way cannula is attached to its
needle adopter .
 The lower end of the barrel of the syringe is then
placed over the fully stretched donor site .
 The needle end part of the 50 cc syringe is then
attached to the other adopter of the 3-way cannula
of the 20 cc syringe

26.  Unlock the 3-way cannula and suck out the air within the 20 cc syringe by 50 cc syringe to
create negative pressure.
Lock the 3-way cannula and evacuate the aspirated air from the 50 cc syringe, again unlock it
and resuck the air to increase further negative pressure within the 20 cc syringe
Lock the 3-way cannula and disconnect 50 cc syringe . This maintains constant negative pressure
within the 20 cc syringe . This pressure produces a rise of 0.5 cm skin inside the syringe.

27.  Appearance of multiple
blisters can be seen through
the 20 cc syringe .
slowly they coalesce to form
single or one to three
unilocular blisters large
enough to be grafted, the
syringes are then disconnected
by unlocking the 3-way
cannula .
Alternately, suction cups/glass
funnels may be used along
with suction
machine/microdermabrasion
machine,so as to create
negative pressure of 250–400
mm Hg.

28.  RECEPIENT SITE PREPARATION :
The recipient site is prepared surgically as previously described earlier in the chapter on split skin
Thiersch grafting.
Different methods include radiofrequency , dermabrasion , Erbium:YAG/carbon dioxide laser or
blistering by methoxsalen plus ultraviolet A,cryoblistering or suction blistering.
 APPLICATION OF GRAFT TO THE RECEPIENT AREA :
The blister is gently cleansed with normal saline and is cut all along its border with curved iris
scissors parallel to the skin surface. The roof is everted over the left hand thumb in such a way
that the dermal surface facing outward .
 The graft is then spread fully over the thumb with the blunt end of the forceps followed by
placing it over the recipient area directly from the thumb and then spread with the reverse end
of the forceps .
 All the grafts are transferred in the similar manner adjacent each other.

30. GRAFT FIXATION :
With sterile moist gauze, the graft is pressed firmly to remove any serous collection underneath
graft; this also helps the graft to adhere to the under surface. The pressure dressing is done with
double layer framycetin tulle, moist gauze, followed sterile gauze and elastocrepe bandage.
REMOVAL OF DRESSING :
The dressing is removed after 5–7 days.
Redressing for another 2–3 days is required.
 Final dressing is removed around 10th day and the patient can go for regular bathing.
The melanocyte transfer takes place within 48–72 hours to the underlying dermal surface. The
dried up graft usually comes out after final dressing is removed, leaving
hyperpigmented/erythematous achromatic areas. Complete repigmentation usually takes place
between 2–3 months with or without medical line of treatment

32. COMPLICATIONS :rare
Infection, hematoma, ecchymosis,
pigmentary changes at donor site and
graft rejection .

33. THIN SPLIT THICKNESS
SKIN GRAFTING

34. INTRODUCTION
Split thickness skin grafting (STSG) involves transfer of epidermis and often the uppermost part
of superficial dermis to achieve transfer of melanocytes and keratinocytes from donor graft to
the underlying dermabraded vitiliginous area.
 The thickness of the graft ranges from 0.1 mm to 0.7mm.
PRINCIPLE : three biological changes are observed
Changes Duration Remarks
Graft take and
adherence
First 72 hrs Most crucial – fibrin bonding takes place 
vascular anastomosis and fibrovascular growth .
Graft
revascularizatio
n
Begins 2-3 days after grafting establishment of direct anastomoses between
graft and recipient blood vessels, a process
known as inoculation
Contracture immediately after harvesting the graft or
after grafting at the recipient site.
Due to contraction of elastin fibres.

35. Patient selection criteria :
 Failure of medical treatment
 site and extent of lesion- low in certain areas such as fingers , elbow and sites prone to
movement .
EQUIPMENT :
Dermabraders: Manual (Dr Manekshaw’s hand held metallic dermabrader) or electrical (wire
brush or diamond fraises)
Skin grafting equipment:
– For harvesting the graft: Humby’s skin grafting knife, Padget’s or Davol’s dermatome, straight
artery forceps with a razor blade or Silver’s razor blade holding knife
 – Graft spreading rods or spatulas
 – Nontraumatizing ring forceps
 Surgical glue: Cyanoacrylate adhesive (N-butyl 2-cyanoacrylate)
 Other equipment includes iris scissors, sterile petri dishes.

36. TECHNIQUE
PREOPERATIVE PREPARATION :
Shaving of the donor and recipient area is important prior to the procedure.
HARVESTING THE GRAFT :
1. DONOR SITE PREPARATION AND ANAESTHESIA
Site : gluteal area (most preferred site ), anterolateral aspect of the thigh, the arms or the
abdomen
After appropriate surgical cleansing, the required donor area is calculated and marked with a
surgical pen.
Topical anesthesia with EMLA may be sufficient, but in certain cases, anesthesia with lignocaine
2% may be needed

37. 2. GRAFT HARVESTING TECHNIQUE :
Normal saline may be used before harvesting to hydrate and lubricate the skin.
The procedure is commenced by an assistant stretching the skin firmly at one end,
applying downward and outward traction with the help of the flat of his hand and
the surgeon providing outward traction at the other end. This is done to flatten the
skin as much as possible and thereby decreasing the drag felt while harvesting the
graft.
 A split thickness graft of uniform thickness is harvested using either a sterile razor
blade mounted on a Kocher’s forceps or a blade holding instrument
Alternatively a hand dermatome, Silver’s knife,24 Humby’s knife25 or a motor driven
Zimmer dermatome can also be used.

39. While harvesting the graft, the cutting blade is held parallel to the skin surface
and a sliding to-and-fro motion is then employed to cut tangentially throughout
the upper dermis.
The angle at which the blade is applied controls the depth of the graft and one
should aim at obtaining a thin, translucent graft. Pin point bleeding at the donor
site signifies suitable depth of the graft taken.
The harvested graft is then transferred to a sterile petri-dish containing normal
saline.
Hemostasis is then attained at the donor site with pressure and the area is
dressed

40. 3. DONOR AREA DRESSING :
Options for dressing the donor site include
occlusive dressings (DuoDerm),
 semiocclusive dressings Tegaderm)- superior than the others ,
semi-open dressings (Vaseline gauze) and
no dressing.
The rate of healing of the donor site is proportional to the number of epithelial appendages
remaining and inversely proportional to the thickness of graft harvested.

41. RECEPIENT SITE :
1. PREPARATION :
After appropriate surgical cleansing, the vitiliginous area is first marked with a surgical pen.
 Anesthesia may be administered using 1% lignocaine, infiltrated into four quadrants, deep
dermal and subcutaneous, covering the vitiliginous area and the surrounding 4–5 cm of normal
perilesional skin.
Alternatively, topical anesthetic cream is applied under occlusion 2–3 hours.
2. DERMABRASION
Dermabrasion must be done evenly all over the depigmented area and 2–3 mm of the
perilesional normal skin, in order to prevent the development of a perigraft halo postoperatively.
 Dermabrasion is done till punctuate papillary bleeding is seen
Alternatively manual dermabrader , Er:YAG laser or an ultrapulse CO2 laser can be used .

42. (A) Lesion before dermabrasion; (B) Dermabraded recipient area; (C) Graft fixed with surgical glue

43. 3. PLACEMENT OF GRAFT :
Once the recipient area is abraded, the graft is transferred onto the dermabraded recipient skin,
taking care to place the dermal surface facing down.
The graft may be placed over a stainless steel bowl surface and punctured with a 24G needle to
make tiny holes in order to prevent serum accumulation.
Ideally, the graft should be little larger than the recipient site, and should extend 3–5 mm beyond
the edges of the abraded area.
The edges of the graft should be evened out with the help of a spatula, a graft spreading rod or
nontraumatizing ring forceps which may be used to place the graft onto the recipient area.
4. IMMOBILISATION :
Proper immobilization of the graft is of utmost importance, and failure to do so may result in
wrinkling and beading of the graft resulting in a relative decrease in the size of the graft.
Collection of serum under the graft and poor immobilization are the two main factors for failure
of graft uptake.

45. COMPLICATIONS
AT THE RECIPIENT SITE AT THE DONOR SITE
Graft rejection Post inflammatory
hyperpigmentation
Textural abnormalities Scarring
Hyperpigmentation Recurrence or Koebnerisation
Perigraft halo
Hypertrophy
Milia
Secondary infection
Reactivation of vitiligo

47. EPIDERMAL NON
CULTURED CELL
SUSPENSION IN VITILIGO

48. Transplantation of autologous cultured and noncultured melanocytes which
involve cell suspension without culture or keratinocyte/melanocyte cocultures6-
10 are gaining popularity.
Transplantation of noncultured melanocytes/ keratinocytes suspension has the
advantage that cell culture is not needed and that skin harvesting from the donor
area, cell separation and application of melanocytes can all be undertaken in a
single 3 hour procedure.
PROCEDURE :
1. Harvesting a skin graft
2. Trypsinization and cell separation
3. Dermabrasion of the recipient (vitiligo) site T
4. ransfer and fixing of melanocyte rich cell suspension.

49. 1. HARVESTING OF SKIN GRAFT :
The lateral aspect of the gluteal region is selected as the donor area.
Under aseptic precautions, a very superficial sample is harvested using a shaving blade held in
straight Kocher’s forceps.
The donor area is dressed with liquid paraffin dressing (Fairlee™) and sterile gauze pad .

50. 2. CELL SEPARATION TECHNIQUE : Most important step and consists of three steps
Trypsinization: The cell separation is done ideally under aseptic precautions in a laminar flow
bench kept in the operation theatre.
The skin sample harvested is transferred to a Petri dish containing 5 ml of the 0.2% w/v trypsin
solution, epidermal side facing upwards, and incubated for 45 min at 37°C
 Removal of excess trypsin : After incubation for 45 minutes-2 hours, the action of trypsin is
neutralized with trypsin inhibitor .
The epidermis is separated from the dermis and transferred to a test tube containing 2 ml of
DMEM:.
The epidermis is further broken into smaller pieces in a Petri dish and washed with the DMEM/F-12
medium and finally transferred to a test tube containing the DMEM/F-12 medium
 Centrifugation : for 6 minutes . Supernatant  discarded . Pellets  suspended in a 1 ml insulin
syringe.

52. 3. DERMABRASION OF THE RECIPIENT SITE
4. TRANSPLANTATION TECHNIQUE :
The cell suspension is spread evenly on the dermabraded area through a pasteur pippette and
covered with collagen dressing (Collomedica laboratories) to hold the cells applied. This is
covered with liquid paraffin and gauze pieces.
Patients are instructed to lie still in the same position for at least 1 hour to ensure cell fixation
and then shifted to a room and further instructed to avoid excessive movements of the treated
area for at least 6 hours .
 POST PROCEDURE INSTRUCTIONS :
All patients are instructed to take complete rest and avoid all vigorous physical activities. Patients
are prescribed oral antibacterial agents for 5 days and nonsteroidal antiinflammatory drugs
(NSAIDs) for 3 days.
The dressings are removed after 1 week in most cases.
 Patients are asked to follow up at weeks 1 and 3 and then at 3 month intervals.

55. CULTURED
MELANOCYTE
TRANSPLANTATION

56. INTRODUCTION
Cultured melanocytes have a donor to recipient area of around 1:100 and hence a very small
donor graft is adequate to cover a very large area.
TECHNIQUE :
The following steps are involved in melanocyte culture:
Technique of culture
 Preparation
Donor site
 Recipient site
 Dressing and follow-up

57. TECHNIQUE OF CULTURE

59. POST PROCEDURE
The patient is asked to give rest to the operated area and to limit mobility at the site.
First follow-up visit is at 7 days when the dressing at both donor and recipient sites is removed.
Both the sites are expected to be reepithelialized by then and appear pink in color.
Over the next 2–4 weeks small brown spots of pigment start appearing on the pink area and by
16–24 weeks maximal repigmentation is expected.
Patients may be advised to undergo phototherapy in the postoperative period narrow band
ultraviolet B/psoralen UVA/psoralen UVA sol (NBUVB/PUVA/PUVA sol) or simply asked to expose
the area to sunlight for 10–15 minutes daily.

60. CRYOPRESERVATION
In order to allow cultured melanocytes to be preserved for prolonged periods, the cells are lifted
into suspension by trypsinization and centrifuged to form a pellet as above.
The pellet is to be then resuspended in cryoprotectant, which is a solution consisting of 8%
dimethyl sulfoxide (DMSO) in undiluted newborn calf serum.
Usually 1 ml of cryoprotectant is to be used for each 10 million cells and the suspension is
transferred to cryotube which is kept on ice for 10 minutes and then placed in a freezer and
frozen at a temperature of –70° to –85°C.
Whenever needed, these cells can be thawed by placing in a 37°C water bath, after which the
suspension is transferred to a test tube containing culture medium.

61. MODIFICATION AND NEW
DEVELOPMENT
 Amniotic Membrane as a Scaffold for Melanocyte Transplantation
 Hyaluronic Acid Micropore Sheets as Scaffold

62. THANK YOU